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Archive for November, 2017

Innovations in Interventional Pulmonology

Thursday, November 30th, 2017

By Venk Lakshminarayanan, MD, Ph.D.

Traditional bronchoscopy is a procedure allowing direct visualization of the tracheobronchial trees of the airway. Historically, the main types of bronchoscopy are rigid and flexible. Flexible bronchoscopy allows for visualization of the lumen, mucosa of the trachea, proximal airways and segmental airways to the third generation of segmental bronchi.

This device allowed for focused obtainment of specimens as part of the evaluation for infectious, malignant or alternative etiologies. Additionally, it is used to diagnose or treat abnormalities within or adjacent to these airways.

Extrinsic compression of the airway from a mass can be assessed as well as direct sampling of peribronchial masses with transbronchial needle aspiration (TBNA). With the advent and initiation of fluoroscopic guidance, there was increased sensitivity in the ability to biopsy peripheral lung lesions which were not directly visualized in an airway.

Bronchoscopy has evolved greatly over the past decade with advances in endoscopic and pathological technologies. Traditional use of fiberoptic bronchoscopy limited tissue sampling to larger (> 2 cm) and more central lesions. With the development of electromagnetic navigation bronchoscopy (ENB) and radial probe ultrasound guidance, we can now access and obtain diagnostic tissue from the peripheral lung nodules with greater sensitivity and at smaller sizes.

Figure 1 - Interventional Pulmonology

Figure 1: Right lower paratracheal lymph node 4R in a patient with a right upper lobe lung mass right mediastinal lymph adenopathy. The white arrow indicates the lymph node. The blue arrow notes the lower border of the azygous vein. Samples taken by L-EBUS were consistent with non-small cell lung cancer. This was consistent with the previously biopsied right upper lobe mass.

These procedures enable the experienced interventionalist to access most mediastinal lymph nodes to provide a complete staging procedure. ENB, which combines bronchoscopy with electromagnetic navigation, allows the interventional bronchoscopist to sample significantly smaller and more peripheral lesions. The use of a linear probe EBUS (L-EBUS) allows for sampling of enlarged mediastinal, hilar lymph nodes or masses, potentially eliminating the need for mediastinoscopy. Endobronchial ultrasound-guided TBNA is a less-invasive alternative in staging of lung cancer in addition to diagnosis.

The presence of lymph node metastasis remains one of the most adverse factors for prognosis in non-small cell lung cancer (NSCLC). The presence of mediastinal lymph node involvement may indicate the presence of stage IIIA or IIIB, thereby suggesting either inoperability or the need for adjuvant chemotherapy and/or radiotherapy.1

Sampling Lymph Nodes and Peripheral Modules

There are three techniques involved in interventional pulmonology in the diagnosis, staging and treatment of potential lung cancers: endobronchial ultrasound (EBUS), electromagnetic navigational bronchoscopy (EMB) and photodynamic therapy (PDT).

Endobronchial ultrasound (EBUS) is a bronchoscopic technique that uses ultrasound to visualize structures adjacent to the wall of the bronchus. It allows for rapid pathologic staging of mediastinal and hilar lymph nodes,1 as well as for pathologic evaluation of nodal disease, which may be seen during radiographic staging.

EBUS is different than endoscopic ultrasound (EUS). While both visualize and guide sampling of lymph nodes, EBUS is performed during bronchoscopy for mediastinal lymphadenopathy. There are two types of EBUS: radial probe EBUS (RP-EBUS) and linear probe EBUS (L-EBUS). The RP-EBUS provides 360-degree circumferential images of the airway wall and surrounding structures.

Figure 2

Figure 2: Electromagnetic Navigational Bronchoscopy (ENB). Image 2A demonstrates the 3-D reconstructing virtual image of the mass following CT scan. Images 2B, 2C and 2D demonstrate the left lower lobe mass by CT imaging. Figure 2E demonstrates the ENB-generated directed pathway to the nodule.

A major advantage of RP-EBUS is its ability to visualize the layers of the airway wall in detail. In contrast, the L-EBUS provides a view that is parallel to the shaft of the bronchoscope with view 30 degrees forward of oblique. Color flow and Doppler features permit identification of vascular, ductal, and cystic structures. The major advantage of L-EBUS is its ability to guide real-time sampling. Coupled with rapid onsite evaluation (ROSE) by a cytopathologist allows for expedited pathologic staging of lymph node. Figure 1 demonstrates a right lower paratracheal lymph node (4R station) seen with an L-EBUS probe, in a patient with a peripheral lung mass with associated adenopathy.

Another area of interventional pulmonology that has rapidly developed recently is electromagnetic navigation bronchoscopy (ENB). ENB allows for more accurate targeting of peripheral lung lesions for biopsy over traditional bronchoscopy with fluoroscopy.The combined modalities of ENB and RP-EBUS can increase the sensitivity of diagnostic yields, especially with peripheral lung nodules, which is of great advantage for nodules as small as 10 mm.

Figure 2 demonstrates a left lower lobe lung nodule biopsied under ENB. Coupled with L-EBUS, this two-staged procedure allowed for diagnostic sampling of the peripheral lung mass and mediastinal lymph nodes. This allowed pathologic staging of this lung mass, and the mediastinal adenopathy results in an expedited diagnostic pathway with increased sensitivity in lung cancer staging. The goal of these combined modalities is to provide a greater patient experience and reduce time to initiate treatment.

Figure 3

Figure 3A: the initial obstructing right main-stem mass consistent with known metastatic adenocarcinoma.

Surgical resection of some early-stage tumors may be contraindicated because of concerns regarding reduced postoperative pulmonary function, ventilation or poor preoperative functional status. Up to 10 percent of patients successfully resected with lung cancer subsequently develop a second primary lung neoplasm.2

Using varying doses of low-intensity laser irradiation, cell growth functions can be stimulated or inhibited.4 One such treatment strategy used on cancer cells PDT, in which cancer cells are treated with a photosensitizer (PS) in combination with laser irradiation. Individually, they are non-toxic. However, with light-activation, reactive oxygen species are generated inducing cancer cell death.4 Cell-specific photosensitizers are in development for future cancer treatment.

Figure 4

Figure 3B: the mass following Photfrin© and first laser light treatment. The mass appears mucoid and less vascular.

After a photosensitizer is administered and the tumor is visualized, the light fiber is introduced through the working channel of the bronchoscope, and the rigid cylindrical tip of the light fiber is embedded into the lesion. This not only protects healthy mucosa from light exposure, but also delivers more energy to the tumor itself.

When the laser light is applied to the target area at the appropriate wavelength, the photosensitizer is activated, causing ROS generation that results in cancer cell death.5 A repeat bronchoscopy is planned 48 hours after the laser light exposure, when the inflammatory response is decreasing and tumor necrosis is achieved. At that time, all debris should be removed bronchoscopically.6

Figure 5

Figure 3C: the mass following the second light exposure and completion of debridement. Note that the right mainstem is patent and there is minimal scarring noted in the airway.

If a second operation may not be feasible for a patient, PDT can provide a therapeutic alternative that spares functional lung tissue required in lung cancer patients.3 Indications for PDT include treatment of micro-invasive endobronchial NSCLC in patients for whom surgery and radiotherapy are not indicated.3 Additionally, PDT can also be used to palliate symptoms in patients with completely or partially obstructing endobronchial masses due to non-small cell lung cancers.3

Figures 3A, 3B and 3C demonstrate a patient with a large right main-stem lesion recurrent NSCLC. In Figure 3A, the obstructing mass is noted in the right main-stem bronchus. Following the initial laser light therapy, the obstructing tumor was noted to have a more mucoid appearance allowing for initiating of debridement (Figure 3B). Serial light exposure and mechanical debridement allowed for local debridement of the complete obstructing mass (Figure 3C).

Interventional pulmonology is a rapidly burgeoning field providing novel and innovating, less-invasive ways of diagnosing and treating a variety of lung diseases. These are just a few of the novel diagnostic and therapeutic procedures available within the field of interventional pulmonology.


References

1. Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med 2004; 350: 379–392

2. Chiaki E, Akira M, Akira S., et al. Results of Long-term Follow-up of Photodynamic Therapy for Roentgenographically Occult Bronchogenic Squamous Cell Carcinoma. Chest 2009; 136(2):369–375)

3. Moghissi K and K Dixon. Update on the current indications, practice and results of photodynamic therapy (PDT) in early central lung cancer (ECLC). Photodiagnosis Photodyn Ther. 2008 Mar;5(1):10-8

4. Crous, A., and H. Abrahamse: Lung cancer stem cells and low-intensity laser irradiation: a potential future therapy? Stem Cell Res Ther. 2013; 4(5):129.

5. El-Hussein A, Harith H, Abrahamse H. Assessment of DNA damage after photodynamic therapy using a metallophthalocyanine photosensitizer. International Journal of Photoenergy. 2012; 2012:1–10).

6. Edell ES, Cortese DA: Photodynamic therapy. Its use in the management of bronchogenic carcinoma. Clin Chest Med. 1995; 16(3):455).

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Georgia Emergency Medicine Leadership & Advocacy Conference

Thursday, November 30th, 2017

November 30 – December 1. The Ritz Carlton Reynolds , Lake Oconee, Greensboro, GA. For more information, visit Georgia College of Emergency Physicians.

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Managing Incidentally Identified Pulmonary Nodules

Monday, November 20th, 2017

By Robert J. Albin, MD, FCCP, FAASM

Due to the ubiquitous availability of CT scanners, coupled with the ever-increasing propensity by physicians across all specialties to order advanced imaging studies, the number of incidentally detected pulmonary nodules has been soaring.

Over a recent 7-year stretch, one large integrated health sys-tem reported a 53 percent increase in the number of CT scans ordered. This trend has resulted in more than 1.5 million newly detected lung nodules in the U.S. annually. Exactly how best to manage these nodules has become an important but prickly dilemma, at times pitting the varied and potentially conflicting perspectives of patients, practitioners, medical societies and practice guideline directives against each other.

What has emerged and become clear is that the management of pulmonary nodules should be driven by the importance of distinguishing those that are malignant from those that are not by balancing the desire to intervene quickly for malignant nodules while avoiding and limiting procedures for those that are benign. What is not clear is how best to achieve this goal.

Figure 1: Right upper lobe [RUL] andleft upper lobe [LUL] solid nodules. The RUL nodule is irregular but contains central calcification. The LUL nodule has irregular borders and is non-calcified. These lesions have remained stable on follow-up exam.

One of the first issues to resolve is to be certain that we are all speaking the same language when it comes to describing nodules. The descriptive nomenclature associated with pulmonary nodules, while endeavoring to be more precise and useful, has created an ever-expanding vocabulary of important distinctions.

Nodules may be solid, subsolid, ground-glass or contain a mixture of these components. They may be ovoid, round, smooth-bordered, spiculated or irregular. It is important to state whether they contain calcium or are non-calcified. While some nodules are detected as solitary abnormalities, in other instances, multiple nodules may be identified. Precise size measurement using proper criteria [the average of long and short diameters, both obtained on the same transverse, coronal or sagittal reconstructed images] adds to prognostic significance. Lobar localization is important, as is the presence or absence of emphysema or fibrosis. These distinctions serve the purpose of trying to identify those nodules with a less than 1 percent probability of being malignant (pCA < 1%), in order to avoid unnecessary testing and procedures.

The Fleischner Society, an international multidisciplinary medical society for thoracic radiology founded in 1969, published their latest recommendations for managing pulmonary nodules this year. Its intent was to cut down on unnecessary follow-up exams and procedures. While extremely useful and worthy of summarizing here, they are not without limitations and controversy. These guidelines apply to incidentally detected nodules in individuals at least 35 years of age.

For a single, solid, non-calcified nodule less than 6 mm in a low-risk patient, no further follow-up is recommended. Even in high-risk patients, the likelihood of this nodule being malig-nant is reported as less than 1 percent. However, suspicious morphology or upper lobe location can raise pCA to the 1 percent to 5 percent range, so a 12-month follow-up study can be considered in this subgroup of patients.

For a nodule 6-8 mm in size in a low-risk patient, a 6-12 month follow-up should suffice if stable. If high risk, additional imaging at 18-24 months should be considered. If the nodule is greater than 8 mm, PET-CT at 3 months is recommended as pCA now approaches 3 percent.

If there are multiple solid, non-calcified nodules less than 6 mm, no routine follow-up is recommended, as this typically represents healed granulomas or intrapulmonary lymph nodes. In a high-risk patient, consider a 12-month follow-up. If any nodule is greater than 6 mm, perform 3-6 month follow-up with optional follow-up at 18-24 months.

For a solitary, pure ground-glass opacity [GGO] less than 6 mm, no routine follow-up is recommended, although 2- and 4-year follow-up should be considered in selected high risk populations. If greater than 6 mm in size, 6-12 month follow-up CT is recommended and repeat imaging every 2 years through 5 years total.

For solitary part-solid nodules, no follow-up is necessary if less than 6 mm. If greater than 6 mm with the solid component less than 6 mm, obtain a follow-up scan in 3-6 months and then annually for 5 years. If greater than 6 mm with a solid component greater than 6 mm, obtain a follow-up scan at 3-6 months. For suspicious morphology or a solid component greater than 8 mm, consider PET-CT, biopsy or resection.

For multiple subsolid nodules less than 6 mm, these are likely infectious or inflammatory. If repeat imaging is stable at 3-6 months, consider scanning at 2 and 4 years. If at least one nodule is 6 mm or larger, rescan at 3-6 months. If persistent, consider multiple primary adenocarcinomas as a potential etiology.

If these recommendations seem confusing or even un-sound, take solace in knowing that you are not alone in this opinion. Unfortunately, the guidelines are based upon very low-quality evidence, as clearly stated in the Society paper. However, despite this, they are generally considered to rep-resent best practice parameters.

Additional shortcomings include the inability to accurately define “low-risk” versus “high-risk” populations. Given that the greatest recent percentage jump in the incidence of lung cancer is among never smokers, who then can be considered to be at “low risk”? Also, how can size be an absolute cutoff criterion for benign versus malignant disease? Every lung cancer was less than 6 mm at some point in its biology. In my opinion, size depends upon when, in the history of this nodule, the scan was performed. A single point in time has never been able to predict a trend.

Figure 2: Multiple bilateral ground-glass opacities of varying sizes. Biopsies have proven these to be multicentric lepidic adenocarcinomas. Management has included surgical resection as well as stereotactic body radiation therapy [SBRT].

I take these guidelines for exactly what they are – guidelines. Good clinical judgment and intuition must always weigh into the decision process. From my perspective, there is no nodule (other than a densely calcified, smooth bordered one) that does not merit additional follow-up imaging. While an extra CT(s) does add to the patient’s total radiation exposure burden, I believe the benefit outweighs the risk and so do the majority of patients.

Not surprising to me, a recent report comparing physicians’ assessment of pretest probability of whether a nodule was benign or malignant demonstrated that physicians were better at predicting malignancy than the frequently cited Mayo Clinic or VA prediction calculators. This is a very sobering finding and reaffirms the importance of clinical experience and “gut” instincts.

In the absence of strong evidence upon which to propose guidelines, the perspective and preferences of the patient and the clinician can and should play a critical role in the decision-making process. Successful management of what has now become a commonplace clinical problem depends upon shared values, concerns and frank dialogue between providers and patients.

Looking ahead, enhancing existing prediction calculators by including novel radiographic measurements, as well as analysis of exhaled, serum and bronchoscopic biomarkers, may aid in distinguishing benign from malignant disease. Until then, it might be a good idea to follow this old medical adage – what would you do if this was your mother?


References

1. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Im-ages: From the Fleischner Society 2017. Radiology 2017.

2. Iaccarino JM, Wiener RS. Pulmonary Nodule Guidelines: What Physicians do When Evidence-Based Guidelines Lack High-Quality Evidence. Chest. 2017; 152(2):232-234.

3. Physician Assessment of Pretest Probability of Malignancy and Adherence with Guidelines for Pulmonary Nodule Evaluation. Chest. 2017; 152(2):263-270.

4. Swensen SJ, Silverstein MD, Edell ES et al. Solitary Pulmonary Nodules: Clinical Prediction Model Versus Physicians. Mayo Clin Proc. 1999; 74(4):319-329

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An Update On Pulmonary Hypertension

Monday, November 20th, 2017

By Micah Fisher, MD

The area of pulmonary hypertension has seen an ex-plosion in interest and therapeutic options over the past 25 years. The first World Health Organization (WHO) international symposium was held in 1973, leading to a standardized definition, a classification system and calls for further investigation. That first classification system, dividing patients between primary and secondary pulmo-nary hypertension, has since been expanded significantly as we have developed a better understanding of the different types of pulmonary hypertension.

The current WHO classification system, last modified in 2013, consists of five types of pulmonary hypertension: 1. Pulmonary arterial hypertension, 2. Pulmonary hyper-tension due to left heart disease, 3. Pulmonary hypertension due to chronic hypoxemia and respiratory diseases, 4. Chronic thromboembolic pulmonary hypertension, and 5. Pulmonary hypertension due to multi-factorial or unclear mechanisms. While our understanding of all these types has improved significantly, at this point, we only have effective targeted therapy for types 1 and 4.

Idiopathic pulmonary arterial hypertension, formerly known as primary pulmonary hypertension, is the prototypic form of pulmonary arterial hypertension. This remains a rare disease with prevalence estimates around 6 people/million. Survival with modern therapy has significantly improved compared to original descriptions, which showed a median survival of 2.8 years.

We now have multiple drug options in each of the three main pathophysiologic pathways, including oral, inhaled, subcutaneous infusions and continuous intravenous infu-sion therapies. These therapies have been very effective in significantly reducing the need for lung transplantation.

Despite the opportunities for ongoing education prompted by the advances in therapeutics, there remains a significant challenge in assuring the right diagnosis is made and appropriate therapy is started. This was highlighted by the multi-center study by Deano et al., published in 2013, which showed that a third of patients who had been given a diagnosis prior to referral had been misdiagnosed, and that more than 50 percent of the patients who had been started on therapy were receiving it contrary to guidelines.

Given the significant side effects and expense of these therapies – some of them costing $150,000 or more a year –this is an issue that needs greater emphasis. Despite our increased understanding, appropriate diagnosis and management remains challenging, which is why all of the major pulmonary hypertension guidelines recommend referral to a center with expertise in managing these patients.

Since the approval of riociguat, an oral soluble guanylate cyclase stimulator, for chronic thromboembolic pulmonary hypertension (CTEPH) in 2013, this disease has received a lot more attention. CTEPH occurs in patients who have incomplete dissolution of pulmonary emboli, leading to chronic pulmonary vascular obstruction and resultant pulmonary hypertension. This appears to be a relatively uncommon complication of pulmonary embolic disease, with most studies suggesting a prevalence between 1 percent and 4 percent of patients followed prospectively after acute pulmonary embolism.

Interestingly, upwards of 50 percent of patients diagnosed with CTEPH will not have a clear history of deep vein thrombosis or pulmonary embolism prior to diagnosis.

Subsequently, all patients being evaluated for pulmonary hypertension, regardless of history of venous thromboembolism are recommended to be screened for CTEPH with a ventilation perfusion scan, which has significantly better sensitivity compared to a CT scan.

Patients diagnosed with CTEPH should be further assessed for surgical candidacy. The operation, a pulmonary endarterectomy, is a major surgery only performed with expertise at a few centers nationwide. The world leader in this operation is the University of California at San Diego, where they perform several hundred annually with published perioperative mortality ranging from 2 percent to 4 percent based on preoperative hemodynamics. Most patients have normalization or near normalization of their pulmonary hemodynamics with surgery and have normal life expectancy after successful surgery, with the only ca-veat that they must remain on life-long anticoagulation.

For years, the only options for CTEPH patients was a pulmonary endarterectomy or lung transplantation. Therapies that had been shown to be effective for pulmonary arterial hypertension had unimpressive results when trialed in patients with CTEPH. That was until riociguat was shown to improve hemodynamics and functional capacity in patients who had inoperable disease or had significant residual pulmonary hypertension after surgery. While these outcomes were robust, they are small compared to the potential outcomes from surgery at an expert center and should not be used to justify not referring patients for a more definitive surgical treatment.

The field of pulmonary hypertension has changed significantly in recent years with updates to the classification system and multiple new therapies. This has led to a significant increase in education targeted at multiple providers. While this has increased awareness, it has also led to a significant amount of over-diagnosis and over-prescribing. Despite these advances, patients with pulmonary hypertension continue to be a diagnostic and management challenge necessitating referral to a pulmonary hypertension center.

 

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DeKalb Medical and Emory Healthcare sign Letter of Intent to form strategic partnership

Monday, November 20th, 2017

DeKalb Medical and Emory Healthcare have signed a Letter of Intent to develop a strategic partnership between the two institutions.

The Letter of Intent signals the beginning of the process to formulate a definitive agreement to bring the two health systems together under the Emory Healthcare system. The partnership would allow for continued growth and expansion of services to even better serve the community. The two institutions anticipate finalizing the partnership in 2018, after receiving final approval from regulatory agencies.

“Both Emory and DeKalb Medical have a strong and historical commitment to providing exceptional care to the community,” says Jonathan S. Lewin, MD, Emory University executive vice president for health affairs and CEO of Emory Healthcare. “We understand the importance of both community hospitals and academic medical centers in delivering optimal care to our patients. A partnership with DeKalb Medical will strategically support these efforts,” says Lewin.

“We are excited about the future,” says Robert E. Wilson, president and CEO of DeKalb Medical.  “Our community has counted on us for 56 years and we’ve always been here – growing to meet our community’s needs.  This partnership will strengthen our ability to continue to deliver high quality community-based healthcare.”

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WellStar Health System expands collaboration with Mayo Clinic

Monday, November 20th, 2017

With a recent expansion of their collaboration with the Mayo Clinic, all WellStar facilities now have access to the resources of the Mayo Clinic Care Network, a national network of like-minded organizations who share a commitment to better serving patients and their families.

WellStar joined the Mayo Clinic Care Network in 2014. Now all 11 hospitals and WellStar Clinical Partners members are included in the Mayo Clinic Care Network. Through digital technology, physicians in the network can collaborate and share the latest medical information. Experts from WellStar and Mayo Clinic work together to further enhance the delivery of healthcare, allowing many patients to receive answers to complex medical questions, close to home.

Specialists across WellStar can now have access to Mayo Clinic’s knowledge and expertise using a variety of electronic tools and services and can consult directly with Mayo Clinic experts on complex diagnosis and treatment plans. These tools and services include:

• eConsults: WellStar Clinical Partner physicians use electronic consulting to connect directly with Mayo Clinic specialists on complex patient cases, which is included at no cost to the patient.

• AskMayoExpert: All members of WellStar’s medical staff have 24/7 access to Mayo-vetted medical information and guidelines through AskMayoExpert, which is a web-based resource created for physicians and other healthcare providers.

•Healthcare Consulting: Related to clinical and business processes, this relationship allows WellStar providers to accelerate patient care innovations.

“At WellStar, we are focused on finding innovative ways to improve patient care,” said John A. Brennan, M.D., executive vice president & chief clinical integration officer. “WellStar is home to some of the most accomplished and preeminent physicians in the Southeast. By collaborating with Mayo Clinic, we are giving our physicians and patients another resource that can improve the health of our community.”

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Avail Dermatology marks growth with new name, additional location

Monday, November 20th, 2017

Newnan Dermatology, currently celebrating nearly three decades of medical care, announced the unveiling of its new name: Avail Dermatology.

“We’ve done this to reflect our growth outside of the Newnan area,” said Avail Dermatology senior partner and president Dr. Mark Ling. “We’ve been in Peachtree City for several years, are now opening in Carrollton, and have more expansion plans on the horizon. So we’re rebranding as Avail Dermatology.”

Dr. Ling says although the name is changing, the practice is not. As Avail Dermatology, the providers, staff, and services remain the same. The practice continues accepting the same insurance plans as before.

“We founded this practice on a commitment to the highest quality of care above all else,” Dr. Ling explained, “and that commitment will be unchanged as we continue to evolve as Avail Dermatology.”

In addition to Dr. Ling, Drs. Jill Buckthal, Mark Holzberg, Steven Marcet, Samit Patrawala, and Joseph Dyer make up the Avail Dermatology physician team. These board-certified professionals treat the breadth of all dermatologic issues, including acne and other skin breakouts, rashes, and skin cancer prevention, diagnosis, and consultation. Avail Dermatology also performs dermatologic surgeries, including Mohs surgery, a micrographic procedure used to remove skin cancers.

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Aging U.S. Population Boosting Demand for Medical Office Buildings

Monday, November 20th, 2017

The aging U.S. population, pressure for healthcare providers to cut costs and new technologies have boosted demand for medical office properties in recent years, according to a new report from CBRE.

The U.S. Census Bureau estimates that the 65+ population will nearly double between 2015 and 2055 to more than 92 million and comprise nearly 23 percent of the country’s total population by that time. Atlanta has seen a 32.1% increase in the population of the 65+ demographic between 2011 and 2016, which is the highest growth among the measured markets in the report. The need for medical office in Atlanta is expected to increase, as Atlanta has a projected 65+ population growth of an additional 25.3% through 2021.

The overall U.S. medical office building vacancy rate was 8 percent in Q1 2017, down by nearly 300 basis points from Q1 2010, and significantly below the vacancy rate for the U.S. office market overall (13 percent in Q1 2017). The pace of vacancy rate decrease accelerated in recent quarters due to stronger user demand, likely driven by the aging U.S. population and increase in the ranks of the insured. The national vacancy rate decreased by the same amount during the past nine quarters (140 bps) as during the prior four years, despite a slight increase in new medical office supply during the past few years. Atlanta’s overall vacancy level has dropped 530 bps (from 19.3% to 14.0%) despite the delivery of 1.2 million sq. ft. of inventory.

Investment in the U.S. medical office sector increased substantially over the past seven years. Total U.S. investment volume in medical office buildings of at least 10,000 sq. ft. rose from just under $4 billion in 2010 to $10.2 billion in 2016. Moreover, total investment in 2016 exceeded the prior annual peak of $7.3 billion in 2006, further reflecting increased optimism in medical office and not simply improvement from the recession.

Through the reuse of former stand-alone buildings (banks, drugstores, etc.), as well as vacant in-line retail, many medical practices have secured high-visibility retail spaces where patients can walk directly into the office from the parking lot. Between three of Atlanta’s top health care providers, more than $2 billion of new construction is underway: Piedmont Atlanta Hospital’s $603 million Marcus Heart and Vascular Center; Children’s Health Care of Atlanta’s $1 billion+ pediatric hospital in northeast Atlanta; and Northside Hospital’s $525 million expansion in five locations throughout the city, including a new medical office tower in Midtown scheduled to open in 2018.

The Evolving Healthcare Landscape

Healthcare providers are facing increasing pressure to reduce costs in the face of uncertain reimbursement rates from both Medicare, Medicaid and private insurance companies and improve patient outcomes. Adopting new technologies is one method for improving healthcare outcomes, but the upfront capital required means that costs must either increase or be trimmed elsewhere. Several key ways in which healthcare providers are attempting to reduce costs are by relocating services closer to where patients live, utilizing video technology to meet with patients remotely and moving more patient volume away from hospitals – the highest-cost facilities – and into lower-cost outpatient facilities, including medical office buildings and urgent-care facilities.

“The evolution of medical technologies is boosting demand for newer product with the infrastructure capable of handling cutting-edge devices and systems,” said Jim Hayden, executive managing director, Healthcare, Global Workplace Solutions, CBRE. “Medical office space that helps providers minimize costs and maximize outcomes, including buildings that support collaboration and can accommodate new technologies that help them achieve these goals, will likely remain in favor.”

Leasing Trends

The five markets with the lowest Q1 vacancy rates were Nashville (2.8 percent), New York (3.2 percent), the San Francisco Bay Area (4.2 percent), Louisville (4.9 percent) and Kansas City (5.5 percent). Nashville registered the strongest medical job growth and New York the fifth strongest over the past five years, contributing to their low availability rates.

Overall asking rents for medical office properties have remained relatively flat for the past seven years, ranging between $22 and $23 per sq. ft. per year. This trend reflects sustained demand for healthcare despite the recession, as well as the relative stability of the medical office tenant base. Specifically, the high cost of tenant build-outs, as well as the importance of proximity to a provider’s patient base and ancillary medical services, compels many tenants to remain in place for long periods of time.

Capital Markets Trends

“As investor appetite for healthcare-related real estate has grown, medical office buildings have emerged as the most popular property type within the sector,” said Chris Bodnar, executive vice president, Healthcare, CBRE Capital Markets. “As yields for traditional real estate asset classes have compressed in recent years, new capital sources—including foreign capital—have entered the medical office sector in search of stability to hedge against any potential correction in the global markets.”

Medical office cap rates have consistently decreased from a high of 8.3 percent in mid-2010 to 6.8 percent as of Q1 2017. On a regional basis, average cap rates have been lowest in the West over the past seven years, below the U.S. average by about 60 bps. However, the spread between the highest and the lowest regional cap rates remained relatively tight during this period, as industry wide trends have a similar impact across the various markets.

“Comparatively moderate regional differences are an attractive feature of medical office asaninvestment class,” said Lee Asher, executive vice president, Healthcare, CBRE Capital Markets. “Because there is demand for healthcare everywhere, investors are generally more willing to look outside the primary markets compared with traditional office investment, and this is apparent in pricing metrics.”

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Jackson Healthcare’s Connecting Kids with Care Expands to Recruit More Volunteer Providers

Monday, November 20th, 2017

A not-for-profit initiative of Jackson Healthcare is moving from pilot to expansion phase, and including more doctors and other licensed medical providers to help impoverished global children get completely free, tech-enabled healthcare. Connecting Kids with Care™ is now accepting additional physicians, nurses, therapists and other advanced practitioner volunteers to add to the corps of more than 100 who have already helped treat 600+ medically at-risk children.

The initiative mobilizes Jackson Healthcare’s core healthcare staffing relationships, technologies and expertise to link children to life-altering care through remote care technology. In less than a year, Connecting Kids with Care™ exceeded its goals, having already begun work with more than 100 humanitarian organizations in 15 countries. It has matched individual children with volunteer medical providers from 13 specialties who have provided direct interventional care, assessment, and care planning for the kids, their local medical staff and caregivers.

Services are 100 percent free for both medical volunteers and those receiving care. The Connecting Kids with Care™ platform utilizes existing technologies so there is no need for anyone to purchase additional equipment. The pairing of personal relationships with technology (live remote video, shared chart reviews, multimedia storage and collaboration tools) allows medical experts to donate their skills with optimal efficiency, and opens up new opportunities for children and medical providers alike.

“Physicians and medical professionals are passionate about providing care for the most remote and vulnerable people in the world,” explains Jackson Healthcare President Shane Jackson. “These children are on a path to shortened or irreparably diminished lives without access to modern medical care. We’re providing connectivity for professionals to help with technology they already own and use every day… and it’s life-changing for both the physicians and children.”

Since launching in pilot phase in July 2016, Connecting Kids with Care™ has facilitated nearly 800 care encounters including adoption medical assessment, urgent and episodic care, chronic disease care plans, chart reviews with physician collaboration, feeding and therapy plans, and clinical decision making. These diagnoses have a broad range of impacts for the children and their caregivers. Orphaned or abandoned children access better immediate care while prospective adoptive parents are better able to anticipate and plan lifetime care.

Its wide reaching response and dramatic individual impacts have lead Jackson to complete the pilot early, and open up the program publicly to more healthcare professionals and organizations around the world.

To learn more about Connecting Kids with Care™, practitioners can visit ConnectingKidsWithCare.org. Signing up does not obligate a provider in any way, but will offer opportunities to volunteer their specialty for a child or children around the world.

Connecting Kids with Care™ (formerly known as the World Care Exchange) is incorporated in Georgia and is applying for non-profit status. It has a full-time staff of four, supported by recruiting and professional services from Jackson Healthcare’s staffing and technology companies.

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Nancy Paris Invested as Member of Venerable Order of St. John

Monday, November 20th, 2017

Nancy Paris, President and CEO of the Georgia Center for Oncology Research and Education, was recently invested as a member of the Venerable Order of St. John in the Priory in the USA. The honor was bestowed in a ceremony at the National Cathedral in Washington DC. The Order of St John is a Christian, chivalric, ecumenical and international community of members who continue more than 900 years’ tradition of helping the sick and the poor of all nationalities, races and creeds.

The tribute recognizes Ms. Paris’ extensive experience creating, directing and raising funds to support community-based health programs. Her leadership at Georgia CORE has helped to improve the quality of cancer care in Georgia and expanded statewide access to clinical research.

Prior to Georgia CORE, she served as vice-president and interim president of the Georgia Cancer Coalition, president of Saint Joseph’s Mercy Care Services, and vice-president of the Georgia Baptist Health Care System. Under her leadership, both Saint Joseph’s Mercy Care Services and the Georgia Baptist Health Care System received numerous foundation and government grants, and many national awards for excellence and innovation.

Ms. Paris also served as director of Hospice Atlanta, vice-president of the Visiting Nurse Foundation and president of AID Atlanta. She is a member of the Board of Directors of MedShare International and the International AIDS Trust; the Atlanta Rotary Club, where she chairs the International Committee; the Dean’s Council of the Rollins School of Public Health at Emory University, and the Board of Visitors of the Georgia Baptist College of Nursing at Mercer University.

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